Self-management of coronary heart disease in angina patients after elective percutaneous coronary intervention:A mixed methods study

Introduction and aim:An estimated 100,000 people in the United Kingdom have percutaneous coronary intervention (PCI) each year to help alleviate angina symptoms. Thereafter, they are expected to modify their coronary heart disease (CHD) risk factors, adhere to medication and effectively manage any recurring angina symptoms. The rate of ‘redo-revascularisation’ in PCI patients seems disproportionately high (75%) when compared to patients who have their angina symptoms managed with coronary artery bypass surgery (<20%). PCI patients’ self-management may be ineffective, however, existing research on this subject is limited by design (e.g. single methods of data collection), methodology (e.g. samples with patients of mixed diagnoses) and lack of theoretical underpinning. Few theories had been used to help explain self-management in a PCI patient group. Researchers have used Leventhal’s Self-Regulation Model to understand how people manage other chronic illnesses but not CHD after elective PCI. Bandura’s Social Cognitive Theory was found to be the basis of self-management but had not been used to explain PCI patients’ CHD self-management. Consequently these two theories were tested to determine their ability to explain self-management in this PCI patient group.The research questions used for this study were: How do patients self-manage their CHD after they have undergone elective PCI? What factors influence patients’ self-management of CHD after elective PCI? To what extent do Bandura’s Social Cognitive Theory and Leventhal’s Self-Regulatory Model help explain self-management of CHD in patients after elective PCI?Design and method:This mixed methods study used a sequential, explanatory design and recruited a convenience sample of patients (n=93) approximately three months after elective PCI. Quantitative data were collected in Phase 1 by means of a self-administered survey and were subject to univariate and bivariate analysis. Path analysis was also used to identify factors that influenced CHD self-management. Phase 1 findings informed the purposive sampling for Phase 2 where ten participants were selected from the original sample for an in-depth interview. Qualitative data were analysed using thematic analysis. Findings: After PCI, 74% of participants managed their angina symptoms inappropriately and one in five stated that they would consider using emergency care services for any recurrence of angina symptoms. Few patients adopted a healthier lifestyle after PCI: 75% were physically inactive, 65% were obese, and 27% made no lifestyle changes at all. Younger participants and those with threatening perceptions of their CHD were more likely to know how to effectively manage their angina symptoms. More educated, self-efficacious participants with fewer co-morbidities and less threatening perceptions of their illness had a greater likelihood of adopting healthier behaviours. Qualitative analysis revealed that intentional non-adherence to some medicines, particularly statins, was found to be an issue. Some participants felt unsupported by healthcare providers and social networks in relation to their self-management and seemed socially isolated. Others reported strong emotional responses to CHD such as fear, shock and disappointment. This had a detrimental effect on their self-management. Neither the Self-Regulation Model nor the Social Cognitive Theory fully explained CHD self-management after PCI. The emotional perceptions participants had of their CHD influenced their cognition and that affected how they coped with their condition. That finding did not align with the Self-Regulation Model. Aspects of the Social Cognitive Theory helped to explain participants’ likelihood of adopting more healthy behaviours but the other components of CHD self-management(manage angina symptoms and adhere to medication)were not explained using this theory.Conclusion:This is the first study to report that patients experienced poor social and healthcare support after elective PCI. Patients had difficulty regulating strong emotions such as fear, shock and disappointment after PCI. This had a detrimental effect on their self-management and neither the Social Cognitive Theory nor the Self-Regulation Model could fully explain CHD self-management after elective PCI. Recommendations for practice / research: Patients after PCI wanted (and should be given) more support to help them manage their CHD yet few accessed or were able to access the traditional means of support: cardiac rehabilitation. Emotional support should be included in such programmes. This is in addition to providing more traditional interventions that focus on: practical support to assist patients in adopting and maintaining healthier behaviours, guidance on angina symptom management and the need for adherence to medication after PCI. Research could be conducted to investigate other means of supporting CHD patients after elective PCI. For example, the effectiveness of telehealth programmes in optimising CHD self-management. An intervention study could be conducted to determine which telehealth programmes are beneficial in optimising CHD self-management. A cohort study could also be considered to explore the effect telehealth has on PCI patients’ revascularisation rates, morbidity and mortality

A mixed method, embedded approach to exploring participation in an exercise referral scheme

The case aims to highlight the potential of using a mixed methods embedded design to understand the effects of an intervention and provide greater understanding of how participant circumstances influence engagement. This case derives from larger a Burdett Trust for Nursing funded project exploring gender perspectives of engagement/non-engagement in an exercise referral scheme in Scotland, United Kingdom. This case focuses on exercise referral participants and gives insight into the value of comparing results, predominantly quantitative longitudinal telephone interviews, with qualitative face-to-face semi-structured interviews. It discusses how writing field notes can add to data collection, raise awareness of bias and aid analysis

Is there an app for that? Mobile phones and secondary prevention of cardiovascular disease.

Purpose of review: Advances in technology coupled with increased penetration of mobile phones and smart devices are rapidly changing healthcare delivery. Mobile phone applications (‘apps’), text messages, and Internet platforms used alone or in combination are now providing interventions targeting people with multiple cardiovascular risk factors. The present article will review the emerging evidence regarding apps and discuss their potential role in providing secondary prevention interventions via mobile phones. Recent findings: Seven recent randomized controlled trials used text messages or apps for six to 12 months, with or without differing combinations of other technology platforms. All studies, involved cardiac and diabetes populations, and demonstrated at least one positive improvement to cardiovascular risk factor profiles. When measured, acceptability of the intervention was high. Summary: Mobile apps and technology can deliver positive outcomes in the management of cardiovascular risk factors. However, because of the complexity of combination interventions, it is difficult to determine the ‘active’ ingredient. A future challenge for researchers and clinicians will be to respond quickly to these rapidly evolving interventions in order to ensure the delivery of effective, evidence-based outcomes

Self-management of coronary heart disease in older patients after elective percutaneous transluminal coronary angioplasty

Objective To explore how older patients self-manage their coronary heart disease (CHD) after undergoing elective percutaneous transluminal coronary angioplasty (PTCA).Methods This mixed methods study used a sequential, explanatory design and recruited a convenience sample of patients (n = 93) approximately three months after elective PTCA. The study was conducted in two phases. Quantitative data collected in Phase 1 by means of a self-administered survey were subject to univariate and bivariate analysis. Phase 1 findings informed the purposive sampling for Phase 2 where ten participants were selected from the original sample for an in-depth interview. Qualitative data were analysed using thematic analysis. This paper will primarily report the findings from a sub-group of older participants (n = 47) classified as 65 years of age or older.Results 78.7% (n = 37) of participants indicated that they would manage recurring angina symptoms by taking glyceryl trinitrate and 34% (n = 16) thought that resting would help. Regardless of the duration or severity of the symptoms 40.5% (n = 19) would call their general practitioner or an emergency ambulance for assistance during any recurrence of angina symptoms. Older participants weighed less (P = 0.02) and smoked less (P = 0.01) than their younger counterparts in the study. Age did not seem to affect PTCA patients’ likelihood of altering dietary factors such as fruit, vegetable and saturated fat consumption (P = 0.237).Conclusions The findings suggest that older people in the study were less likely to know how to correctly manage any recurring angina symptoms than their younger counterparts but they had fewer risk factors for CHD. Age was not a factor that influenced participants’ likelihood to alter lifestyle factors

COVID-19 and cardiac rehabilitation

The British Association for Cardiovascular Prevention and Rehabilitation (BACPR), the British Cardiovascular Society (BCS) and the British Heart Foundation (BHF) have issued a joint position statement ‘Retention of cardiac rehabilitation services during the COVID-19 pandemic’

Living with myocardial ischaemia and no obstructive coronary arteries: a qualitative study

Objective To explore the lived experience of people with myocardial ischaemia with no obstructive arteries. Design Qualitative study using semistructured interviews. Setting Telephone interviews with 17 participants living in the UK. Participants 17 people (2 males, 15 females; aged 31–69 years) with a presumed or confirmed diagnosis of myocardial ischaemia with no obstructive arteries, recruited via social media and online patient-led support forums. Results Five themes were generated. Theme 1 describes the wide range of experiences that participants described, particularly the frequency and intensity of symptoms, and the uncertainty and fear that symptoms commonly provoked. Theme 2 describes the major impact on social relationships, employment and other aspects of everyday life. Theme 3 illustrates challenging and traumatising experiences participants described around pathways to diagnosis and accessing medical support. Theme 4 highlights the lack of consensus and clarity that participants had been confronted with around treatment and management. Theme 5 describes coping and supportive strategies valued by participants. Conclusions This study provides insight into the challenges of living with myocardial ischaemia with no obstructive arteries. Findings highlight the significant psychological impact on people living with these conditions and the need for improvements in diagnosis, support and long-term management

How has technology been used to deliver cardiac rehabilitation during the COVID-19 pandemic? An international cross-sectional survey of healthcare professionals conducted by the BACPR

Objective To investigate whether exercise-based cardiac rehabilitation services continued during the COVID-19 pandemic and how technology has been used to deliver home-based cardiac rehabilitation. Design A mixed methods survey including questions about exercise-based cardiac rehabilitation service provision, programme diversity, patient complexity, technology use, barriers to using technology, and safety. Setting International survey of exercise-based cardiac rehabilitation programmes. Participants Healthcare professionals working in exercise-based cardiac rehabilitation programmes worldwide. Main outcome measures The proportion of programmes that continued providing exercise-based cardiac rehabilitation and which technologies had been used to deliver home-based cardiac rehabilitation. Results Three hundred and thirty eligible responses were received; 89.7% were from the UK. Approximately half (49.3%) of respondents reported that cardiac rehabilitation programmes were suspended due to COVID-19. Of programmes that continued, 25.8% used technology before the COVID-19 pandemic. Programmes typically started using technology within 19 days of COVID-19 becoming a pandemic. 48.8% did not provide cardiac rehabilitation to high-risk patients, telephone was most commonly used to deliver cardiac rehabilitation, and some centres used sophisticated technology such as teleconferencing. Conclusions The rapid adoption of technology into standard practice is promising and may improve access to, and participation in, exercise-based cardiac rehabilitation beyond COVID-19. However, the exclusion of certain patient groups and programme suspension could worsen clinical symptoms and well-being, and increase hospital admissions. Refinement of current practices, with a focus on improving inclusivity and addressing safety concerns around exercise support to highrisk patients, may be needed

Gender differences in uptake, adherence and experiences: a longitudinal, mixed methods study of a physical activity referral scheme in Scotland, UK

Physical activity referral schemes (PARS) are implemented internationally to increase physical activity (PA) but evidence of effectiveness for population subgroups is equivocal. We examined gender differences for a Scottish PARS. This mixed-method, concurrent longitudinal study had equal status quantitative and qualitative components. We conducted 348 telephone interviews across three time points (pre-scheme, 12 and 52 weeks). These included validated self-reported PA and exercise self-efficacy measures, and open-ended questions about experiences. We recruited 136 participants, 120 completed 12-week and 92 completed 52-week interviews. PARS uptake was 83.8% (114/136) and 12-week adherence for those who started was 43.0% (49/114). Living in less deprived areas was associated with better uptake (p=0.021) and 12-week adherence (p=0.020), and with male uptake (p=0.024) in gender-stratified analysis. Female adherers significantly increased self-reported PA at 12 weeks (p=0.005) but not 52 weeks. Males significantly increased exercise self-efficacy between baseline and 52 weeks (p=0.009). Three qualitative themes and eight subthemes developed; gender perspectives, personal factors (health, social circumstances, transport and attendance benefits) and scheme factors (communication, social/staff support, individualisation and age appropriateness). Both genders valued the PARS. To increase uptake, adherence and PA, PARS should ensure timely, personalized communication, individualised, affordable PA and include mechanisms to re-engage those who disengage temporarily

Research priorities relating to the delivery of cardiovascular prevention and rehabilitation programmes: results of a modified Delphi process

Objective: The purpose of this British Association for Cardiovascular Prevention and Rehabilitation (BACPR) research priority setting project (PSP) was to identify a top 10 list of priority research questions for cardiovascular prevention and rehabilitation (CVPR). Methods: The PSP was facilitated by the BACPR clinical study group (CSG), which integrates as part of the British Heart Foundation Clinical Research Collaborative. Following a literature review to identify unanswered research questions, modified Delphi methods were used to engage CVPR-informed expert stakeholders, patients, partners and conference delegates in ranking the relevance of research questions during three rounds of an anonymous e-survey. In the first survey, unanswered questions from the literature review were ranked and respondents proposed additional questions. In the second survey, these new questions were ranked. Prioritised questions from surveys 1 and 2 were incorporated in a third/final e-survey used to identify the top 10 list. Results: From 459 responses across the global CVPR community, a final top 10 list of questions were distilled from an overall bank of 76 (61 from the current evidence base and a further 15 from respondents). These were grouped across five broad categories: access and remote delivery, exercise and physical activity, optimising programme outcomes, psychosocial health and impact of the pandemic. Conclusions: This PSP used a modified Delphi methodology to engage the international CVPR community to generate a top 10 list of research priorities within the field. These prioritised questions will directly inform future national and international CVPR research supported by the BACPR CSG